Management of the nontoxic multinodular goitre: A European questionnaire study

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Abstract
The optimum management strategy for the patient with a multinodular nontoxic goitre is still a matter of debate. Our aim was to assess the attitudes towards management of such patients throughout Europe by means of a questionnaire. The questionnaire was circulated to all clinician members of the European Thyroid Association (ETA). A case report was followed by diagnostic investigations and choice of therapy in the index case (a 42-year-old woman with an irregular nontender bilaterally enlarged thyroid of 50–80 g and no clinical suspicion of malignancy). Eleven variations of the basic case report were proposed in order to evaluate the impact on management of each alteration. One hundred and sixty-seven members replied to the letter, and 120 individuals from 22 countries completed the questionnaire (corresponding to approximately two-thirds of the clinical members of the ETA). Based on the index case, serum TSH was the routine choice of 100%, and serum free T4/T4-index was included by 74%. Serum TPO autoantibodies, Tg autoantibodies and calcitonin were measured by 65%, 49% and 32%, respectively. The median number of blood tests used was four (range 1–11). Considerable intercountry variations were seen in the preferred imaging methods. Ninety-one percent of the clinicians would use at least one imaging modality. Ultrasound (US) was used by 84%, thyroid scintigraphy by 76%, and both methods by 69%. US had first priority (53% vs. 19% for scintigraphy). If scintigraphy was performed, fine-needle aspiration cytology was routinely used by 17% (inhomogeneous uptake) and 95% (dominant ‘cold’ area), and 63% used US-guidance. L-T4 treatment was supported by 52% of the clinicians, iodine supplementation by 4%, radioiodine by 6% and surgery by 10%. In the case of a suppressed serum TSH, radioiodine treatment was preferred by 44%, while surgery was the favoured recommendation in four clinical variations with a large goitre or suspicion of malignancy. Marked differences between the countries were suggested by L-T4 therapy being the dominant treatment in Italy, France and Germany in contrast to the prevailing use of radioiodine in Denmark and a wait and see policy in the UK. Fundamental differences between European countries exist as regards diagnosis and treatment of the multinodular nontoxic goitre suggesting difficulties in reaching a consensus.